A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Maintain IV fluid infusion and assess adequacy of hydration

Provide continuous sedation for pain relief

Insert an indwelling (Foley) catheter and monitor hourly urinary output

Prepare for endotracheal intubation and ventilatory support

Answer and Explanation

The Correct Answer is A

A) Maintain IV fluid infusion and assess adequacy of hydration: This is the best nursing action as adequate hydration is crucial in managing sickle cell crisis. It helps to reduce blood viscosity and prevent further sickling of red blood cells, which is especially important in the context of pneumonia, as dehydration can exacerbate the crisis.

B) Provide continuous sedation for pain relief: While managing pain is essential, continuous sedation is not the most appropriate first step in this situation. Pain management should be addressed, but hydration and treating the underlying causes (like pneumonia) take priority.

C) Insert an indwelling (Foley) catheter and monitor hourly urinary output: While monitoring urinary output can be important, it is not the most immediate action in this case. Focus should be on hydration and addressing the sickle cell crisis rather than on urinary output at this time.

D) Prepare for endotracheal intubation and ventilatory support: Although respiratory distress is a concern with pneumonia, the current pulse oximetry reading of 96% indicates adequate oxygenation at this time. Preparing for intubation should not be the first action unless the patient shows signs of respiratory failure or severe distress.

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Correct Answer is D

Explanation

A. "I will have some pain that is similar to a toothache.": This statement shows an understanding that discomfort can occur after a bone marrow aspiration, which is a common experience.

B. "I understand that this is a sterile procedure.": This demonstrates awareness of the importance of sterility during the procedure to prevent infection, which is accurate.

C. "The nurse will check the puncture site at least every 4 hours after the procedure.": This indicates an understanding of the need for monitoring the puncture site for complications such as bleeding or infection, which is an appropriate expectation.

D. "The nurse will give me one 650 mg tablet of Aspirin for pain when the procedure is over.": This statement indicates a need for additional teaching because aspirin can increase the risk of bleeding, particularly after a procedure involving puncturing the skin. Generally, acetaminophen (Tylenol) would be recommended for pain relief instead of aspirin.

Correct Answer is ["116"]

Explanation

To calculate the infusion rate, we'll follow these steps:

Determine the total volume to be administered:

8 mL (drawn from the vial) + 50 mL (dilution with NSS) = 58 mL

Calculate the infusion rate:

58 mL ÷ 30 minutes = 1.93 mL/minute

Convert mL/minute to mL/hour:

1.93 mL/minute × 60 minutes/hour = 116 mL/hour

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A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

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Naxlex Comprehensive Predictor Exams

The nurse understands that a client who has had a bone marrow aspiration to assist in the diagnosis of anaemia requires additional teaching when they state:

Correct Answer is D

Explanation

Correct Answer is ["116"]

Explanation

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